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303 Fantasia LnATC Number: 4964 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will nction satisfactorily for any given period of time. System Type:` A S.T. Manufacturer the Tank Date Tank Size lc;GC% Pump Tank Size System Installed By: J a' W0`f-04"e-1W 5 E.H. Specialist: Date: /`) _l �t W QC c C 50 I I� f f DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990005212 Tax PIN/EH #: 5788-65-8332 Billed To: Jamie Barnes Subdivision Info: Reference Name: Location/Address: 303 Fantasia Lane -27006 Proposed Facility: Residence Property Size: 2.00 Acres ATC Number: 4964 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will nction satisfactorily for any given period of time. System Type:` A S.T. Manufacturer the Tank Date Tank Size lc;GC% Pump Tank Size System Installed By: J a' W0`f-04"e-1W 5 E.H. Specialist: Date: /`) _l �t W QC c C 50 I I� f f DCHD 11/06 (Revised) � - Y DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 ATC Number: 4964 Site Type: QNew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms J # BathroomsD- 5 # People c;L-Basement Bbasement plumbinggB--- Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) r _� Lot Size ��Cf� Type of Water Supply: ❑County/City 2<11 ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size GAL. Pump Tank-,F� f► -AL. Cr (� 1' Trench Width �� Max. Trench Depth Rock Depth IALinear Ft. Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 - 9:30a.m. on the day of installation. Telenhone # (3361751-8760. /06 we -W r o �r (D No�•s � � ePa�rI ` f � �` G✓l� a SIC. � o Environmental Health Specialist �2_6�.em Date: —W DCHD 11/06 (Revised) I AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION. Account #: 990005212 Tax PIN/EH #: 5788-65-8332 Billed To: Jamie Barnes Subdivision Info: Reference Name: Location/Address: 303 Fantasia Lane -27006 Proposed Facility: Residence Property Size: 2.00 Acres ATC Number: 4964 Site Type: QNew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms J # BathroomsD- 5 # People c;L-Basement Bbasement plumbinggB--- Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) r _� Lot Size ��Cf� Type of Water Supply: ❑County/City 2<11 ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size GAL. Pump Tank-,F� f► -AL. Cr (� 1' Trench Width �� Max. Trench Depth Rock Depth IALinear Ft. Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 - 9:30a.m. on the day of installation. Telenhone # (3361751-8760. /06 we -W r o �r (D No�•s � � ePa�rI ` f � �` G✓l� a SIC. � o Environmental Health Specialist �2_6�.em Date: —W DCHD 11/06 (Revised) I Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990005212 Tax PIN/EH M 5788-65-8332 Billed To: Jamie Barnes Subdivision Info: Address: 303 Fantasia Lane Location/Address: 303 Fantasia Lane -27006 City: Advance Property Size: 2.00 Acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: New ❑Repair ❑Expansion Permit Valid for: t3'57Y—ears ❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms %• People ""Basement❑ Basement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) / Design Flow(GPD): a Type of Water Supply: ❑County/City 0 ell ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial 1.e0 , 3'X '5j Repair 7 Site Plan ( ►a� `�° � �� NPS � C'.' eO �i'/ Welt Lf 121 � 2g� TWV& Xly l Environmental Health Specialist i., 11 -Or Date 4/— (r APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Permit uthorization To Construct(ATC) lAloth Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed i 2 Contact Person O_WV _ Cef w.e._S Billing Address 0 3 N i 4 ve" Home Phone City/State/ZIP L 20 0 U Business Phone Name on Permit/ATC if Different than Above. Mailing Address YKUMK 1 Y 1 N r UKN1A 11U1N City/State/Zip *''Date House/Facility Comers F1 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is vaIa for 60 7?nths with site plan, no expiration with complete plat.) Owner's Name _ nM i & R/'Nes Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# 3 3— Subdivision Name(if applicable) Sectiou/LQt# To answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes ❑No Does the site contain jurisdictional wetlands? ❑Yes ❑No Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? ❑Yes ❑No Will wastewater other than domestic sewage be generated? ❑Yes ❑No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 73 # Bathrooms '�. 7 Garden Tub/Whirlpool ❑Yes ❑No Basement: es ❑No Basement Plumbing: FtVes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Conventional ccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ell ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Date Sign given ❑Yes ❑No Revised 11/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # 7/ Invoice # &97/ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation AP�P.L�ICA T•.IqQ ' ON Tax PIN/EH #: 5788-6EMBERTY INFORMATION Billed To: Jamie Barnes Subdivision Info: Reference Name: Location/Address: 303 Fantasia Lane -27006 Proposed Facility: Residence Property Size: 2.00 Acres Date Evaluated: �'� `—� Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 0 — G _ HORIZON I DEPTH Texture group Consistence X � Structure E.- Mineralogy HORIZON II DEPTH Texture group C Consistence Structure r A C Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON / SAPROLITE CLASSIFICATION ' LONG-TERM ACCEPTANCE RATE .17 0:3:15 SITE CLASSIFICATION: 1" of EVALUATION BY. _7 1 l<% S LONG-TERM ACCEPTANCE RATE: 3 D73 OTHER(S) PRESENT: REMARKS: LEGEND 0 1 Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP -Flood plain H - Head slope Texture S -Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CQNSISTENCF mDi&.t VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3Y&I NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralog 1:1, 2:1, Mixed Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) TTAR - T.nna-term arrPntgnP,- rata - an1hinu/ft7 on ■■■■■■■■■■■■■■■■■■■■■�■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■o■■m■■■■m■■■■■■ecce■ NOUN ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■eee■■■EEE■■■E■EEEE■NN■ ■■o■■■■■■■■■■E■■ss■■M■■■ ■■MNEME■■■■■■■■E■■■■BENE■■■■■■E■ ■■■ecce■■■eee■■■■■■■e�■■■■■ecce■ ■■E■■■EENE■EN■■eee■EEIIN■■■EE■■■■ ■■■■M■ME■■■■■EE■ENNEMIIEEE■EEEEE■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■ MEMO ■■NE■1■ENr�■■Mar■■EEEN■�■■ ■E■ ■■MEM■ME■ ■■■E■■■■■ ■E■EMEE■e ■MME■EEs1I ■■■■■■s■II ■■■EEE■s11 ■MM■E■s■11 ■■■■■■MEIN ■■■■MEMO■ ■■■■■■■■■ ■■■■s■■E■ ■EMMEMEMEMEMEM■ ■O■MEMEMEMME■M■ ■E■■■E■■M■■E■■■ ■EE■EMEME■■■■M■ ■■■EM■■■E■■■■■■ ■■■■■■■■■■■■■■■ --------------- ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ Mar■■■■■�■■■■■■ ■■ ■■NN■■ ■■II ■■■EEE■■■■EEM■&i ■ENE■■■EMMMMMMRI ■■s■■■■■■■■MM■■ ■EEM■■■E■■■■E■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■M■■■■■■■■■ ■■■E■E■■s■■■■■■ ■MMME■■EM■s■■■■ ■■ME■EEE■■■■E■■ ■■■M■■EME■ ■EM■M■MME■ MMEMMEMMEM ■■■■MEM■M■ ■■MEM■MME■ ■EMM■■M■■■ MEMMUMMEME MEMEMEMMEM MEMEMMMEEM ■ENNEN ■■■E■■ ■■■■■■ ■■■E■■ ■E■■■■ ■■■■E■ ■■■NE■ ■E■■E■ ■■■■E■ ■EE■■■ ■E■■E■ ■E■s■■ mosso■ ■■■■■■ ■■■E■■ ■E■NE■ MOSSES ■EE■E■ ■■MONS ■ ■